Nursing Elites

1. A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?

• A. Clamp the chest tube prior to transferring the client to a wheelchair.
• B. Disconnect the chest tube from the drainage system during transport.
• C. Keep the drainage system below the level of the client's chest at all times.
• D. Empty the collection chamber prior to transport.

Correct answer: C

Rationale: When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.

2. A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?

• A. Monitoring urine output
• B. Checking blood glucose levels
• C. Assessing for chest pain
• D. Monitoring electrolyte levels

Correct answer: C

Rationale: Assessing for chest pain is crucial in post-MI clients as it can indicate complications such as reinfarction or ischemia.

3. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

• A. Production of pink sputum
• B. Tracheal deviation
• C. Drainage greater than 70 mL/hr
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

4. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) for a client receiving O2 at 4 liters per nasal cannula?

• A. Apply water-soluble ointment to nares and lips.
• B. Periodically adjust the oxygen flow rate.
• C. Remove the tubing from the client's nose.
• D. Turn the client every 2 hours or as needed.

Correct answer: A

Rationale: When a client is receiving oxygen at a high flow rate, it can cause drying of the nasal passages and lips. Therefore, a comfort measure that can be delegated to unlicensed assistive personnel (UAP) is applying water-soluble ointment to the client's nares and lips. Adjusting the oxygen flow rate should be done by licensed nursing staff, not UAP. Removing the tubing can disrupt the oxygen delivery and should be performed by trained personnel. Turning the client every 2 hours is a general comfort measure but is not specific to addressing the drying effects of oxygen therapy.

5. A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?

• A. I will take my medication as prescribed.
• B. I will need to have regular follow-up chest x-rays.
• C. I will be able to return to work immediately.
• D. I will use tissues to cover my mouth when I cough.

Correct answer: C

Rationale: Clients with tuberculosis should not return to work until they are no longer contagious and have been cleared by their healthcare provider. This usually requires several weeks of treatment. The other statements are correct and indicate understanding.

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